Statement of Understanding
This statement is to inform you of confidentiality, payment and cancellation policy.
Everything you share is confidential. The only exceptions to confidentiality are as follows:
- Counselors are Mandated Reporters and are required by law to report cases to the authorities of suspected: (1) child abuse; (2) elder abuse; (3) serious threat of harm to self; (4) serious threat of harm to someone else.
- If you sign a Release of Information to a specific person or agency, only the information authorized will be released.
- Records subpoenaed by a court of law may be released without your consent.
- Records may be reviewed for research and/or quality purposes. Individual identifying information will be removed prior to this process.
- For Skype appointments as confidentiality cannot be guaranteed
In addition to “Confidentiality” above, I have read and understand my privacy rights as outlined according to HIPAA (Health Insurance Portability and Accountability Act (www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/).
There is a 24-hour cancellation policy. To avoid being charged for an unattended session, simply cancel by either calling or emailing 24-hours prior to your appointment time.
Insurance is not accepted at this time.
All sessions are to be paid prior to your session time. Follow the booking instructions on the website to pay for your appointments
By scheduling this session, I realize it is understood I have read and understand the content above.
Note: Phone Therapy is not recommended for those who have thoughts of suicide or homicide. For further assistance, you may call the National Suicide Hotline at 1800-SUICIDE (1-800-784-2433), 911, your local emergency services or go to your nearest emergency room.